Single-lumen Endotracheal Tube Research Articles

Comparison of early postoperative pulmonary complications between two-lung ventilation with artificial pneumothorax and one-lung ventilation with bronchial blockade in patients undergoing minimally invasive esophagectomy: a retrospective propensity score-matched cohort study.

Two-lung ventilation (TLV) with artificial carbon dioxide (CO2) pneumothorax is used during the thoracoscopic phase of minimally invasive esophagectomy (MIE). However, the impact of TLV with artificial pneumothorax on postoperative pulmonary complications (PPCs) after MIE is unclear. This study aimed to compare the incidence of early PPCs between TLV with CO2 pneumothorax and one-lung ventilation (OLV) with bronchial blockade in patients undergoing MIE. Five hundred ninety-three patients with esophageal cancer who underwent elective MIE with two-field lymph node dissection were analyzed. Patients in the TLV group were intubated using a single-lumen endotracheal tube and underwent surgery using TLV with artificial CO2 pneumothorax. Patients in the OLV group underwent surgery using OLV with a bronchial blocker. Patient characteristics and intraoperative and PPC data were collected and analyzed. Propensity score matching (PSM) was performed to reduce confounding bias. The TLV and OLV group comprised 513 and 80 patients, respectively. PSM matched 197 TLV group and 73 OLV group patients. Incidence of pneumonia within the first 3 days of surgery was higher in the TLV group (11.7% vs. 4.1%) but the difference was not significant (P=0.06). The incidence of infiltrates on chest radiography was 36.0% in the TLV group and 28.8% in the OLV group (P=0.26). Incidence of other major PPCs requiring treatment and major non-pulmonary postoperative complications did not significantly differ between the groups. Length of hospital stay was significantly longer in the TLV group (13.0 vs. 11.0 days; P=0.03). Compared with OLV with bronchial blockade, TLV with CO2 pneumothorax did not reduce the incidence of early PPCs after MIE.

Comparison of Time to Intubation of a Double-Lumen Endobronchial Tube Utilizing C-MAC® Versus GlideScope® Versus Macintosh Blade: A Randomized Crossover Manikin Study.

Macintosh blade direct laryngoscopy is widely used for endotracheal intubation. It may, however, provide an incomplete view of the glottis in patients with challenging airway anatomy. Consequently, various video laryngoscopes have been developed to enhance the visualization of the glottis and facilitate intubation. Yet, the effectiveness of these video laryngoscopes for intubation using a double-lumen endotracheal tube (DLT), which is longer, larger, and more rigid and has a linear configuration as opposed to the naturally semicircular curvature of a single-lumen endotracheal tube, remains uncertain. We hypothesized that video laryngoscopes would be more efficient for DLT intubation compared to the Macintosh blade in an adult manikin. Ninety-four anesthesia providers, comprising 67 residents, 15 fellows, and 12 attendings, attempted to intubate an adult manikin with normal airway anatomy (Laerdal, Wappingers Falls, NY, USA) using a 37 Fr left-sided DLT. Three different intubation devices were used: the C-MAC® video laryngoscope (Karl Storz GmbH & Co. KG, Tuttlingen, Germany), the GlideScope® video laryngoscope (Verathon Inc., Bothell, WA), and the Macintosh blade direct laryngoscope-were used. Each participant intubated a manikin once with each of the three devices. Participants were randomized via a crossover design with the order of devices determined by using a Latin square design. Time to intubation and the number of failed intubations (esophageal intubation) were compared across the three different devices. Mean times to intubation for the C-MAC®, GlideScope®, and Macintosh blades were 18.57 ± 0.77, 36.26 ± 2.69, and 20.76 ± 0.96 seconds, respectively. There was a statistically significant difference (P<0.001) between the GlideScope® and the other two laryngoscopes. The times for C-MAC® and Macintosh blades were not significantly different. There were two instances of first-attempt failed intubation with the Macintosh. Both the C-MAC® and the Macintosh blades proved more efficient in terms of time to DLT intubation in the manikin with normal airway anatomy, when compared to the GlideScope®. Considering the occurrence of first-attemptfailed intubation, the C-MAC® was the most effective device among the three laryngoscopes for timely successful DLT intubation in the adult manikin. Further studies are needed to confirm these results in human subjects.

Single Lung Ventilation versus Two Lung Ventilation in Video Assisted Thoracoscopic Lung Surgeries

Abstract Background VATS is being widely used nowadays in thoracic surgeries. One lung ventilation (OLV) is a technique routinely used in thoracic anesthesia to facilitate thoracic surgery. Double-lumen tubes (DLT) remain the most popular and reliable choice for one lung ventilation especially in adult patients. Objective To evaluate single lung ventilation as an alternative to conventional ventilation in video assisted thoracoscopic lung surgeries despite the claimed intra operative and post-operative hypoxemia which could be avoided or even minimized by changing ventilatory setting. Patients and Methods After approval of anaesthesiology department scientific and ethical committees in Ain Shams University Hospitals, Patients were included in the study in form of two equal groups (each of 30 patients). Group A: (no.=30) Patients did lung surgeries with single lung ventilation using double lumen endotracheal tube. Group B: (no.=30) Patients did lung surgeries with two lung ventilation using conventional single lumen endotracheal tube (two lung ventilation). Results In our study it was found that intraoperative hypoxemia (SaO2 &amp;lt; 90%) occurred during some cases of single lung ventilation in 4 out of 30 cases. However, it was irrelevant to any other intraoperative or post-operative complication. Moreover, it was irrelevant to post-operative arterial oxygen saturation or any end organ complication. In our study also all comorbidities which can affect arterial oxygen saturation were excluded from the study from the start. However, better studies are urgently needed to investigate an individual “best oxygen content” concept for each patient undergoing one-lung ventilation. Conclusion The result of this study comparing single lung ventilation versus to lung ventilation in video assisted thoracoscopic surgeries concerning mainly intraoperative and post-operative hypoxia demonstrated that intra operative hypoxia occurred in some cases of single lung ventilation. However, this intraoperative hypoxia was irrelevant to post-operative hypoxia or any intraoperative or post-operative complications. So, our study recommends that using DLT for one lung ventilation is ideal for video assisted thoracoscopic lung surgeries, providing better surgical field, lesser surgery duration and better surgeon satisfaction.

Video-assisted thoracic surgery for spontaneous pneumothorax under two-lung ventilation and single-lumen endotracheal tube intubation.

This study investigated the feasibility of video-assisted thoracic surgery (VATS) performed under two-lung ventilation (TLV) and single-lumen endotracheal tube (SLET) intubation in patients with spontaneous pneumothorax. From January 2016 to December 2019, 344 patients who underwent VATS with spontaneous pneumothorax, whether primary or secondary, were enrolled. The surgery was performed through TLV using SLET intubation or one-lung ventilation (OLV) using double-lumen endotracheal tube (DLET) intubation. Patient data were collected retrospectively from medical records and compared with an emphasis on the time required for anesthesia and surgery. The average anesthesia time was 72.6±17.8 min for TLV and 89.9±24.3 min for OLV (P<0.001). The average operating time was 42.1±16.2 min for TLV and 54.7±23.8 min for OLV (P<0.001). The average time from the onset of anesthesia to incision was 23.6±7.0 min for TLV and 27.6±9.5 min for OLV (P<0.001). There was no case of conversion to OLV using DLET intubation during surgery with TLV using SLET intubation. Removal of the chest tube took 1.6±1.1 days for the TLV group and 2.3±3.6 days for the OLV group (P=0.017). Patients were discharged at 2.7±1.2 days after surgery for the TLV group and 3.2±2.3 days after surgery for the OLV group (P=0.009). TLV using SLET intubation could shorten the time required for anesthesia-related procedures and surgery. In addition, it can be a beneficial surgical and anesthetic option for pneumothorax.

A Chest Tube Inadvertently Inserted into Tracheal Lumen

The accompanying images demonstrate the presence of the distal end of a chest tube in the tracheal lumen just above the carina. These images are from a patient who developed coughing and massive air leak after chest tube placement. Inadvertent tracheal injury during chest tube placement should heighten suspicion for concomitant lung injury.1 Massive air leak in tracheobronchial disruption leads to low tidal volumes, lung atelectasis, and increased work of breathing. Consequently, respiratory distress may ensue, necessitating urgent intubation. In hemodynamically stable patients, bronchoscopy-guided endotracheal intubation is encouraged. This allows for airway examination, confirmation of tracheal injury site, and determination of the best strategy for achieving lung isolation to facilitate surgical repair.Lung isolation allows for mechanical ventilation of the uninjured lung and helps avoid pressurization of surgical repair site, minimizing risk of further disruption. In patients with bronchial injury, advancing the single-lumen endotracheal tube or placing a double-lumen endotracheal tube into the contralateral uninjured bronchus are possible options. In patients with carinal injury, creation of a large tracheostomy through which small endotracheal tubes are advanced into bilateral main stem bronchi allows delivery of mechanical ventilation while minimizing pressurization of the repaired carina.2 Tenuous cardiopulmonary status before induction of anesthesia or inability to maintain adequate oxygenation during one-lung ventilation may necessitate institution of peripheral extracorporeal membrane oxygenation to facilitate surgical repair. Importantly, removal of the chest tube leads to loss of its tamponade effect on lacerated pulmonary vessels. As this can precipitate massive hemorrhage, it is important to establish invasive arterial monitoring and large-bore intravenous access before anesthesia induction.3The authors declare no competing interests.

Anesthetic Management of a Case of Airway Bleeding During Pulmonary Artery Mass Resection

Airway bleeding is an uncommon complication of pulmonary artery surgery. It can be caused by fragile bronchopulmonary collateral, vessel perforation, and reperfusion pulmonary edema. Early discovery of the breach and anesthetic management are very important for the prognosis of the patients. We present a case of 58-year-old female diagnosed with left pulmonary artery mass. After the resection of the mass, the surgeon injected saline into the pulmonary artery and the patient was ventilated manually. Air bubbles were found in the artery, indicating a breach between the airways and the pulmonary circulation. Fiberoptic bronchoscopy revealed the breach on the lateral wall of the left lower bronchus. We replaced the single lumen endotracheal tube with a 32 left-sided double-lumen endobronchial tube to prevent the contamination of the right lung. After a consultation with the thoracic department, left lower lung lobectomy was performed.

One-Lung Ventilation during Rigid Bronchoscopy Using a Single-Lumen Endotracheal Tube: A Descriptive, Retrospective Single-Center Study.

Using one-lung ventilation (OLV) through a single-lumen endotracheal tube (SLT) in the untreated lung during rigid bronchoscopy (RB) and jet ventilation, high oxygenation can be guaranteed, whilst procedures requiring thermal energy in the other lung are still able to be used. This pilot study aimed to examine the bronchoscopy-associated risks and feasibility of OLV using an SLT during RB in patients with malignant airway stenosis. All consecutive adult patients with endobronchial malignant lesions receiving OLV during RB from 1 January 2017 to 12 May 2021 were included. We assessed perioperative complications in 25 RBs requiring OLV. Bleeding grades 1, 2, and 3 complicated the procedure in two (8%), five (20%), and five (20%) patients, respectively. The median saturation of peripheral oxygen remained at 94% (p = 0.09), whilst the median oxygen supply did not increase significantly from 0 L/min to 2 L/min (p = 0.10) within three days after the bronchoscopy. The 30-day survival rate of the patients was 79.1% (95% CI 58.4-91.1%), all of whom reported an improvement in subjective well-being after the bronchoscopy. OLV using an SLT during RB could be a new treatment approach for endobronchial ablative procedures without increasing bronchoscopy-associated risks, allowing concurrent high-energy treatments.

Airway management in “tubeless” spontaneous-ventilation video-assisted thoracoscopic tracheal surgery: a retrospective observational case series study

BackgroundSurgeon and anesthetist share the airway in a simpler way in the resection and reconstruction phase of tracheal surgery in tubeless spontaneous-ventilation video-assisted thoracoscopic surgery (SV-VATS). Tubeless SV-VATS means stable spontaneous ventilation in the resection and reconstruction phase to anesthesiologist, and unobstructed surgical field to surgeon. What’s the ideal airway management strategy during “Visual Field tubeless” SV-VATS for tracheal surgery is still an open question in the field.MethodsWe retrospectively reviewed 33 patients without sleeve and carina resections during the study period (2018–2020) in our hospital. The initial management strategy for these patients was spontaneous ventilation for intrathoracic tracheal resection and reconstruction. We obtained and reviewed medical records from our institution’s clinical medical records system to evaluate the airway management strategy and device failure rate for tracheal resection in Tubeless SV-VATS.ResultsBetween 2018 and 2020, SV-VATS was first attempted in the 33 patients who had intrathoracic tracheal surgery but without sleeve and carina resections. All patients underwent bronchoscopy (33/33) and 8 patients (8/33) received partial resection before surgery. During the surgery, the airway device comprised either a ProSeal laryngeal mask airway (ProSeal LMA) (n = 27) or single lumen endotracheal tube (n = 6). During the resection and reconstruction phase, Visual Field tubeless SV-VATS failed in 9 patients, and breathing support switched to plan B which is traditional ventilation of a single lumen endotracheal tube for cross field intubation (n = 4) and ProSeal LMA alongside a high-frequency catheter (high-frequency jet ventilation, HFJV) (n = 5) into the distal trachea ventilation. Preoperative respiratory failure or other ventilation-related complications were not observed in this cohort.ConclusionBase on current analysis either ProSeal LMA or endotracheal tube is an effective airway management strategy for tubeless SV-VATS with appropriate patient selection. It also provides breathing support conversion option when there’s inadequate ventilation.

OGC P49 Case report: Ivor Lewis oesophagectomy requiring one lung ventilation in a patient with a previous laryngectomy

Abstract Background A 68 year old patient with squamous cell carcinoma (SCC) of lower oesophagus (T3N0M0) presented for Ivor Lewis oesopphagectomy (ILO) following neoadjuvant chemoradiotherapy. Four years previously the patient had undergone total laryngectomy, radical right neck dissection with right pectoralis major flap and bilateral adjuvant radiotherapy for hypopharyngeal SCC (pT3N2bM0). A tracheal stoma was present with speaking valve in-situ. An ILO was planned requiring one lung ventilation (OLV) to facilitate surgical access. In our institution, OLV is routinely achieved via double lumen endotracheal tube (DLT), although endobronchial blocker through single lumen endotracheal tube or laryngeal mask airway and endobronchial intubation with a single lumen tube are potential options. Post laryngectomy the method used for lung isolation is limited and care must be taken not to traumatise the stoma site or surrounding tissue. Additionally, the angulation formed by the trachea and stoma mean a DLT is often not suitable while specific double lumen tracheostomy tubes may have too great a diameter for a small stoma. Surgically, close relations of the tumour to gastro-oesophageal junction, left diaphragmatic crus and descending thoracic aorta made suitability for resection uncertain, despite two negative staging laparoscopies. We describe the anaesthetic and surgical management of this interesting case. Methods General anaesthesia was delivered via an intravenous induction and maintenance was with sevoflurane. Airway management included bag mask ventilation with a neonatal facemask followed by placement of an 8mm reinforced endotracheal tube through the tracheal stoma. Prior to right thoracotomy a right sided 9Fr VivaSight endobronchial blocker (Ambu) was placed under direct vision using a single use Ambu aScope™ 4 Broncho Slim fibreoptic bronchoscope. OLV was successful using this method; SpO2 ≥96% (FiO2 0.6) and peak inspiratory pressure 18–20cmH2O-1. Analgesia comprised intrathecal morphine, right erector spinae plane local anaesthetic block and infusion catheter and morphine PCA. Abdominal phase was undertaken laparoscopically. The hiatus was noted to be fibrotic following chemoradiotherapy and a small capsular breach of the left lobe of liver occurred, controlled with Surgiflo (Ethicon). A right thoracotomy was performed through the 6th intercostal space. Right lung was deflated and surgical access was adequate. OrVil (Covidien – Medtronic) anastomosis was attempted but the anvil was unable to pass through the pharynx, therefore a purse string applicator was applied and OrVil staple used. The left pleura was also breached during dissection. One left and two right chest drains were placed. Results Postoperatively, analgesia was adequate and the patient did not require any cardiovascular or respiratory support. However, on first postoperative day it was noted that the speaking valve was not functioning causing significantly hoarse voice. A valve leak was detected and though hard to know the precise cause, it was assumed that it had become dislodged via either anaesthetic procedures, surgical handling or a combination. Despite some improvement in the symptoms over the first post-operative week, the patient also experienced airway soiling on commencing oral intake and after review by ENT a new valve was successfully sited and all symptoms resolved. Although a minor and easily rectifiable complication, the ‘loss of voice’ was very distressing for the patient. The patient had an otherwise uneventful postoperative course and was discharged home on day-11. Clinic review at six weeks revealed the patient had made a complete recovery and had resumed all normal activities. Histology showed scattered small foci of moderately differentiated SCC infiltrating the muscularis propria (stage ypT2). Longitudinal margins were clear of both dysplasia and malignancy. There was no evidence of lymphatic, venous or perineural invasion. One of 12 lymph nodes showed metastatic SCC. Adjuvant course of Nivolumab immunotherapy is currently planned. Conclusions We have presented an unusual case of previous laryngectomy plus requirement for OLV for ILO. The use of an endobronchial blocker via a reinforced endotracheal tube has been shown to be a successful airway management strategy. Speaking valve displacement and/or malfunction is a potential complication in such cases and should form part of preoperative counselling. Close liaison between surgical, anaesthetic and ENT teams is essential in the management of complex and unusual cases and, as we have demonstrated, strong teamwork leads to successful outcomes for patients.

Case Report: Differential lung ventilation with jet ventilation via a bronchial blocker for a patient with a large thoracogastric airway fistula after esophagectomy

A thoracogastric airway fistula (TGAF) is a rare and potentially fatal complication of esophagectomy for esophageal and cardia carcinomas. Isolation of the fistula and pulmonary separation is necessary during the surgical repair of a tracheal fistula. However, currently, the reported airway management techniques are not suitable for patients with a large TGAF. This case study presents an alternative technique for performing differential lung ventilation in a patient with a thoracogastric airway fistula. A 70-year-old man was diagnosed with a thoracogastric airway fistula situated above the carina after esophagectomy, and a thoracoscope-assisted repair of the fistula and pectoralis major myocutaneous flap transplantation were scheduled. The patient could not tolerate one-lung ventilation and the complex intubating operation due to aspiration pneumonia and the size (3.5 cm × 1.7 cm) of the fistula. We, therefore, performed differential lung ventilation in which an extended 6.5#single-lumen endotracheal tube was inserted into the left main bronchus and a 9Fr bronchial blocker was placed in the right main bronchus by using the video-flexible intubation scope. The right lung was selectively inflated with jet ventilation, while positive pressure ventilation was maintained through the left endotracheal tube. The value of SPO2 remained above 95% throughout the operation. For patients with a large thoracogastric airway fistula, differential lung ventilation of a combination of positive pressure ventilation and jet ventilation is useful. Inserting an extended single-lumen endotracheal tube into the left main bronchus and a bronchial blocker into the right main bronchus could be another way of providing differential ventilation for patients with a large thoracogastric airway fistula.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Challenge of Lung Isolation in Patients with Vocal Cord Implants.

Glottic closure insufficiency increases the risk of aspiration and pneumonia, particularly in the elderly. Medialization thyroplasty is an open surgical procedure for treating glottic incompetency by approximating both vocal folds. The vocal fold medialization is achieved by inserting an implant to bring the nonmobile fold to the unaffected side. Lung isolation in patients with vocal cord implantation poses a unique challenge. Understanding the risks of different modalities of lung isolation and their impacts on the vocal cord implant is crucial to implementing a specifically tailored plan. Preoperative bronchoscopy, intraoperative video laryngoscopy, and bronchoscopy are ideal methods for assessing the vocal fold implants and guiding the lung isolation technique. Bronchial blocker through a single-lumen endotracheal tube may be the preferred choice to avoid the injury of the stretched vocal cords and dislodgement of the implant by a larger diameter double-lumen tube.

Providing one-lung ventilation in posttracheostomic tracheal stenosis for thoracoscopic plastic of the right diaphragm dome

The article is devoted to the consideration of a clinical case of providing artifcial one-lung ventilation for performing thoracoscopic plastic of the right dome of the diaphragm in a patient with grade 3 posttracheostomy cicatricial tracheal stenosis. The patient is presented after a new coronavirus infection COVID-19 from 2020, prolonged mechanical ventilation through a tracheostomy tube (74 days), the development of medium thoracic cicatricial tracheal stenosis of grade 3 (the lumen of the narrowest part of the trachea is 4 mm) after decannulation and the development of relaxation of the right dome of the diaphragm (according to CT data, the dome is located at the level of the IV intercostal space). The frst stage under conditions of combined general anesthesia and high-frequency ventilation of the lungs was performed to restore the lumen of the trachea by bougienage of the stenosis area with tubes of a rigid endoscope under the control of a fberoptic bronchoscope with further nasotracheal intubation with a thermoplastic single-lumen endotracheal tube with a diameter of 8.0 with a cuff. At the second stage, during thoracoscopic plastic of the right dome of the diaphragm, to provide artifcial one-lung ventilation, a bronchial blocker was used, introduced through the same endotracheal tube into the right main bronchus under the control of a fberoptic bronchoscope.

Efficacy of two-lung ventilation with different tidal volume assisted by CO 2 pneumothorax for airway management in patients undergoing radical resection of esophageal cancer using combined laparoscopic and thoracoscopic approach

Objective: To evaluate the efficacy of two-lung ventilation with different tidal volume assisted by CO2 pneumothorax for airway management in patients undergoing radical esophagectomy using combined thoracoscopic and laparoscopic approach. Methods: One hundred and eighty patients undergoing radical esophagectomy using combined thoracoscopy and laparoscopy under general anesthesia from the Affiliated Cancer Hospital of Zhengzhou University between February and September 2019 were randomly divided into three groups (group V1, V2, V3, n=60) according to the tidal volume (TV) used. The TVs of group V1-V3 were 4, 5, 7 ml/kg during thoracoscopic surgery, respectively. All the patients were intubated with a single-lumen endotracheal tube and underwent two-lung ventilation assisted by continuous positive pressure CO2 pneumothorax in group V1, V2 and V3, with the CO2 pressure of 10 mmHg (1 mmHg=0.133 kPa) and the frequency of 20 times/min. Mean arterial pressure (MAP) and heart rate (HR) were recorded before thoracoscopic surgery (T1), 30 minutes after thoracoscopic surgery (T2), at the end of thoracoscopic surgery (T3), after thoracoscopic surgery and 30 minutes after two-lung intermittent positive pressure ventilation, respectively. The results of arterial blood gas were collected at T1, T2, T3 and T4. Recovery time from anesthesia, consciousness recovery time, and lung collapse condition were recorded. Results: At T2, the value of MAP in group V1 was (81±10) mmHg, which was higher than those of group V2 [(69±7) mmHg] and group V3 [(71±8) mmHg], with a statistically significant difference (F=9.270, P<0.05). Meanwhile, at T2, the value of HR in group V1 was (83±7) times/min, which was higher than those of group V2 [(68±6) times/min] and group V3 [(71±7) times/min], and there was a statistically significant difference (F=23.460, P<0.05). However, at T2, the values of arterial partial pressure of oxygen (PaO2) in three groups were (262±16), (249±16) and (241±20) mmHg, respectively, with no statistically significant difference (F=1.929, P>0.05). At T3, the value of arterial partial pressure of carbon dioxide (PaCO2) in group V3 was (46±5) mmHg, which was lower than those of group V1 [(63±9) mmHg] and V2 [(62±10) mmHg], with a statistically significant difference (F=20.890, P<0.05). Moreover, at T3, the value of pH in group V3 was (7.35±0.04), which was higher than those of group V1 (7.28±0.04) and V2 (7.32±0.04), and there was a statistically significant difference (F=9.309, P<0.05). Additionally, the satisfaction rates of lung collapse in group V3 was 57.1%, which was lower than those of group V1 (94.7%) and group V2 (96.3%), with a statistically significant difference (χ²=7.601, P<0.05). There was no statistical significance in the time of awakening and consciousness recovery among three groups (F=1.020 and 1.110, both P>0.05). Conclusion: The two-lung ventilation with 5 ml/kg tidal volume assisted by CO2 pneumothorax has advantages in terms of hemodynamics and surgical field exposure, and is more suitable as the appropriate dose for respiratory management in patients undergoing radical resection of esophageal cancer using combined thoracoscopic and laparoscopic approach.

Improvement of surgical complications using single-lumen endotracheal tube intubation and artificial carbon dioxide pneumothorax in esophagectomy: a meta-analysis

BackgroundEsophageal cancer has a poor prognosis. Surgery is the main treatment but involves a high risk of complications. Some surgical strategies have tried to eliminate complications. Our meta-analysis tried to find the benefits of single-lumen endotracheal tube intubation with carbon dioxide (CO2) inflation.MethodsA systematic search of studies on esophagectomy and CO2 inflation was conducted using PubMed, Medline, and Scopus. The odds ratio of post-operative pulmonary complications and anastomosis leakage were the primary outcomes. The standardized mean difference (SMD) in post-operative hospitalization duration was the secondary outcome.ResultsThe meta-analysis included four case-control studies with a total of 1503 patients. The analysis showed a lower odds ratio of pulmonary complications in the single-lumen endotracheal tube intubation in the CO2 inflation group (odds ratio: 0.756 [95% confidence interval, CI: 0.518 to 1.103]) compared to that in the double-lumen endotracheal tube intubation group, but anastomosis leakage did not improve (odds ratio: 1.056 [95% CI: 0.769 to 1.45])). The SMD in hospitalization duration did not show significant improvement. (SMD: -0.141[95% CI: − 0.248 to − 0.034]).ConclusionsSingle-lumen endotracheal tube intubation with CO2 inflation improved pulmonary complications and shortened the hospitalization duration. However, no benefit in anastomosis leakage was observed.

Use of bronchial blocker to facilitate left double-lumen tube placement.

Use of bronchial blocker to facilitate left double-lumen tube placement.

Effects of the anesthesiologist\u2019s experience on postoperative hoarseness after double-lumen endotracheal tube intubation: a single-center propensity score-matched analysis

BackgroundPostoperative hoarseness after general anesthesia is associated with patient discomfort and dissatisfaction. A recent large retrospective study showed that single-lumen endotracheal tube intubation by a trainee did not alter the incidence of postoperative pharyngeal symptoms compared with intubation by a senior anesthesiologist. However, there is limited information about the relationship between the anesthesiologist’s experience and hoarseness after double-lumen endotracheal tube intubation. We tested the hypothesis that double-lumen endotracheal tube intubation performed by a trainee increases the incidence of postoperative hoarseness compared to intubation by a senior anesthesiologist.MethodsThis retrospective observational study included patients who underwent lung resection between April 2015 and March 2018 at a university hospital. Double-lumen endotracheal tube intubation was carried out with a Macintosh laryngoscope. We divided the patients into 2 groups - one group comprised of patients who were intubated by a trainee anesthesiologist with < 2 years of experience, and the other group comprised of those who underwent intubation by a senior anesthesiologist with ≥2 years of experience. The primary outcome was the incidence of postoperative hoarseness 24 h after surgery and we collected data on postoperative hoarseness using a checklist of postanesthetic adverse events. One-to-one propensity score matching was conducted and P values < 0.05 were considered statistically significant.ResultsThere was a total of 256 eligible patients, of which 153 underwent intubation by trainee anesthesiologists, and the remaining 103 patients were intubated by a senior anesthesiologist. The one-to-one propensity score matching resulted in 96 pairs of patients for the groups. The incidence of postoperative hoarseness 24 h after surgery was significantly higher in patients who were intubated by a trainee anesthesiologist than in patients who were intubated by a senior anesthesiologist (9.4% vs. 2.1%, respectively; P = 0.03).ConclusionsDouble-lumen endotracheal tube intubation by trainee anesthesiologists with < 2 years of experience increased the incidence of postoperative hoarseness 24 h after surgery compared to intubation by senior anesthesiologists with ≥2 years of experience.

Low Tidal Volumes Are Associated With Slightly Improved Oxygenation in Patients Having Cardiac Surgery: A Cohort Analysis.

Mechanical ventilation with low tidal volumes appears to provide benefit in patients having noncardiac surgery; however, whether it is beneficial in patients having cardiac surgery is unclear. We retrospectively examined patients having elective cardiac surgery requiring cardiopulmonary bypass through a median sternotomy approach who received mechanical ventilation with a single lumen endotracheal tube from January 2010 to mid-August 2016. Time-weighted average tidal volume (milliliter per kilogram predicted body weight [PBW]) during the duration of surgery excluding cardiopulmonary bypass was analyzed. The association between tidal volumes and postoperative oxygenation (measured by arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen ratio [PaO2/FIO2]), impaired oxygenation (PaO2/FIO2 <300), and clinical outcomes were examined. Of 9359 cardiac surgical patients, larger tidal volumes were associated with slightly worse postoperative oxygenation. Postoperative PaO2/FIO2 decreased an estimated 1.05% per 1 mL/kg PBW increase in tidal volume (97.5% confidence interval [CI], -1.74 to -0.37; PBon = .0005). An increase in intraoperative tidal volumes was also associated with increased odds of impaired oxygenation (odds ratio [OR; 97.5% CI]: 1.08 [1.02-1.14] per 1 mL/kg PBW increase in tidal volume; PBon = .0029), slightly longer intubation time (5% per 1 mL/kg increase in tidal volume (hazard ratio [98.33% CI], 0.95 [0.93-0.98] per 1 mL/kg PBW; PBon < .0001), and increased mortality (OR [98.33% CI], 1.34 [1.06-1.70] per 1 mL/kg PBW increase in tidal volume; PHolm = .0144). An increase in intraoperative tidal volumes was also associated with acute postoperative respiratory failure (OR [98.33% CI], 1.16 [1.03-1.32] per 1 mL/kg PBW increase in tidal volume; PHolm = .0146), but not other pulmonary complications. Lower time-weighted average intraoperative tidal volumes were associated with a very modest improvement in postoperative oxygenation in patients having cardiac surgery.

Robotic‐assisted cardiac surgery without lung isolation utilizing single‐lumen endotracheal tube intubation

This study assessed the feasibility and outcomes of performing robotic cardiac surgery without lung isolation using single-lumen (SL) endotracheal tube intubation. Between 2013 and 2017, 132 patients underwent robotically-assisted atrial septal defect closure. A retrospective analysis was performed of 23 patients (11 males, mean age 30.9 ± 5 years) who underwent robotic surgery with double-lumen (DL) endotracheal tube intubation (group 1) compared with 109 patients (57 males, mean age 32.4 ± 7.5 years) undergoing the same procedure with SL endotracheal intubation (group 2). The patient groups were compared in terms of demographic characteristics, operative data, and complications. The technical feasibility of the robotic procedure without lung isolation was evaluated. There were no mortality, intraoperative complication, and conversion. Mean total anesthesia time was significantly decreased in the SL intubation group (238.3 ± 22.4 vs 227.2 ± 21.2 minutes; P = .025). First-pass intubation success was significantly higher in the SL intubation group (17 [73.9%] vs 98 [89.9%] patients; P = .032). Mean ventilation time (10.9 ± 5.3 hours), intensive care unit stay (16.8 ± 10.1 hours), and the length of hospital stay (3.8 ± 1.2 days) was significantly decreased in patients with SL tube (P < .05). Unilateral reexpansion pulmonary edema was observed in five (21.7%) patients with DL tube, whereas no patient with SL tube had this complication. SL endotracheal tube intubation without lung isolation is a feasible and safe airway alternative in robotic cardiac procedures. This approach resulted in shorter anesthesia time, ventilation time and the length of hospital stay. Port placement and robotic set-up can be uneventfully performed without lung isolation.

An Anesthetic Approach to Off Pump Complete Sternal-Sparing Implantation of a Fully Magnetically Levitated LVAD

Our experience has demonstrated benefits of off pump minimally invasive left ventricular assist device (LVAD) implantation. We describe the anesthetic management for this innovative technique addressing technique-specific issues such as arrhythmia management, hemostasis, right heart failure and postoperative pain control. In this single-center case series, we analyzed data from five consecutive patients (one surgeon and one anesthesiologist) who underwent implantation of a fully magnetically levitated LVAD using complete sternal-sparing approach without cardiopulmonary bypass (CPB). Anesthetic concerns were identified which would compromise the potential outcomes of this innovative technique. Five patients were implanted off pump via bilateral thoracotomies (80% male, median age 59 yrs). Three patients required preoperative impella placement and four required preoperative VA-ECMO. Minimally invasive cardiac surgery usually requires one lung ventilation to optimize exposure; however, 100% of these patients were managed with a single lumen endotracheal tube. Arrhythmia protocols included magnesium infusion, amiodarone bolus/infusion and potassium administration; successfully eliminating the occurrence of any fatal arrhythmias or defibrillation during placement of the inflow ring. Rapid ventricular pacing and steep Trendelenburg position during coring of the left ventricular apex minimized blood loss. Right ventricular failure was successfully averted in all patients using vasoactive agents, phosphodiesterase 3 inhibitors, aerosolized synthetic prostacyclin agonists and adherence to strict hemodynamic parameters post LVAD insertion. Use of peripheral nerve blocks (left serratus anterior plane block and right subpectoral interfascial plane block) decreased postoperative pain, minimized opioid use and allowed for faster extubation (median 20.75 hrs) and discharge from intensive care unit (median 6 days). 100% of these patients survived to discharge. We have developed a comprehensive protocol to address multiple anesthetic concerns involved with the challenging off pump complete sternal-sparing technique LVAD implantation, achieving 100% survival to discharge in this initial cohort. Further studies are needed to corroborate this single-center experience.